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As of mid-2013, there were still more than 1,300 short-term, independent, acute care hospitals in the United States. Within these organizations, many thoughtful trustees are trying to decide if their hospital should continue to stand alone or seek affiliation. Although this is a decision that only can be made at the board level, many trustees wonder when physicians should become involved in deliberations.

Because physicians can be independent from, employees of or board members of hospitals, there is no single right answer. Each hospital and board must determine what works best for them. Some relevant factors regarding physician involvement include: the quality of the relationship that exists between physicians and the board; how competitive the marketplace is; and the degree of transparency that the board wants with regard to an affiliation process.

That being said, it's almost always better to have physicians involved fairly early in the merger or affiliation process because, ultimately, they can make or break a deal. Physician input in many instances can bring two organizations together or, conversely, keep two cultures apart. Physician leaders can provide valuable insight into physicians' practice patterns, their plans for the future, provision of services, and so on. Remember, doctors — not administrators — engage with patients every day and admit them to hospitals.

There are seven ways trustees can bring physicians into the partnership process.

1 Leverage the opinions of the people who know best. If a physician already serves on the board, cultivate him or her as an asset who can help the organization navigate physician relationships. If there's no physician on the board, then work with the C-suite. The senior leadership team works each day with the doctors and can be very helpful in identifying which physicians to involve in the merger process. They know these physicians personally and professionally and have built up the trust you will need to get constructive feedback.

Other viable representatives may be found within medical leadership, such as the vice president of medical affairs or the chief medical officer. High-profile physicians, such as your highest admitters, or contracted physicians serving in radiology, lab or the emergency department also are good choices. These doctors tend to have incredible influence within the hospital because their work requires that they know and collaborate with a large number of other physicians. In addition, doctors in these specialties are usually very loyal to their hospital and typically do not practice at other hospitals.

2 Take the first steps with a retreat. If you're trying to achieve physician buy-in for a merger or affiliation (or even the exploration of such), it can be helpful to schedule a half-day, off-site retreat with physician leaders on neutral ground. Trustees should have clear goals for the meeting, communicate them at the start of the session and emphasize them throughout to ensure meaningful participation and results. A retreat can be the ideal platform for physician leaders to learn more about the exploration process or the impending decision, hear the rationale behind any decision, and offer their insights and feedback.

3 Involve different physicians at different times. Boards should determine what kind of leadership or advisory role they want a physician to fulfill: the respected elder statesman; the influential doctor with the ability to rally support for a decision; or the fearless critic with a knack for identifying potential problems. Additionally, discussions with physicians need not always take place in the boardroom. Other methods and avenues of soliciting input — both formally and more casually — may take place in different settings and at different times along the way. These may include a survey, email correspondence, town hall meeting or personal conversations.

Again, the board may want to turn to the CMO for advice. Trustees need to get feedback from younger physicians, stable, midcareer physicians, and physicians nearing retirement. All have different perspectives and motivations; as a result, no single person can accurately represent the needs of the entire physician body.

4 Once physicians are invited to participate in the process, stress the importance of openness and honesty among all engaged parties. No one wants to be told only part of the story or a partial truth. Physicians need to know that if they're being included, it's because their opinions have value and not just because the board needs a vote. If a hospital joins a system, the other hospital will set the culture at the combined organization. Employed physicians are keenly in tune with culture and will know quickly if a potential partner organization is physician-friendly.

Physicians also know who's nearing retirement, who's in the prime of their career, and who's just starting out — and how these three physician demographics will fit into the new organization.

5 Give the physicians specific assignments. Don't invite doctors into the process without a purpose; clearly identify a meaningful role for them and then fully leverage their efforts. Consider asking them to help determine where various physicians and groups stand with respect to the hospital's affiliation potential with other hospitals or systems. Or they may answer such questions as: How is quality perceived by the physicians? What value does the hospital bring to potential partners and what would the impact be on the physicians? What concerns might others have about the organization?

6 It's hard to keep secrets in hospitals, so be prepared for leaks. Partnerships are hot topics, so physicians and others often speculate about the what-ifs. If confidentiality is an issue, then include the physicians you believe are most able to keep your confidence, limit the number of doctors in the process, remind them about their responsibilities, and ask everyone to sign a confidentiality agreement.

7 Decide how board members will answer questions from those outside the decision-making process. Questions will come from many constituents, including physicians. Will all questions be referred to a single individual (probably the board chair or even a lead physician on the board) or will any board member respond to any physician who asks for confirmation or for details. If the latter, determine the response in advance.

This balancing act can get tricky. If a trustee tells a physician that there's nothing afoot, but then a month later announces a deal, there will be at least one physician (or more) who may never again trust what the board says. Make communication planning an integral part of the process to ensure that inevitable questions take no one by surprise.

It's hard to overestimate how essential physicians are to the eventual success or failure of any partnership. Involving physicians in the decision-making process shouldn't be viewed as something boards must postpone, or even avoid, as they determine the fate of their organizations. Instead, boards should understand that physician participation is an opportunity to more fully vet a critical decision from the perspective of some very important stakeholders — a viewpoint that is essential before a final decision is made.

Kathy Kronenberg (kkronenberg@insighthp.com) is principal and chief operating officer, Insight Health Partners, St. Petersburg, Fla.